Clinical Study Of THRIVE In General Anesthesia For The Removal Of Foreign Body In The Esophagus

Esophageal foreign body removal is a common emergency procedure in otolaryngology-head and neck surgery,requiring intraoperative jaw relaxation and shared upper airway,and is usually performed with endotracheal intubation under general anesthesia.Performing tracheal intubation excites the sympathetic nervous system,leading to a dramatic increase in catecholamines,which causes an increase in blood pressure and an increase in heart rate,leading to high rates of cardiovascular events^[1,2].In the absence of spontaneous breathing and mechanical ventilation,THRIVE technology as a new asphyxiation oxygenation technology delivers patients with a high flow of heated and humidified gas through a nasal cannula,effectively improving oxygenation and extending the safe apnea time,suitable for adults with short pharyngeal surgery^[3-5].There are no clinical reports on the use of THRIVE for foreign body extraction in the upper esophagus.In this study,we intend to investigate the safety and efficacy of THRIVE for upper esophageal foreign body extraction by comparing it with conventional intubated mechanical ventilation.ObjectiveThe purpose of this study is to investigate the safety and efficacy of THRIVE in upper esophageal foreign body extraction and to provide evidence-based evidence for its clinical application,with the intention to develop a new"tubeless anesthesia"strategy for upper esophageal foreign body removal.MethodsA case-control study was conducted.A total of 46 adult patients,aged 18-65 years,BMI 18.0-30.0kg/m²,American Society of Anesthesiologist（ASA）class I to III,preoperative assessment of non-difficult airway,expected operative time within 30 min,undergoing upper esophageal foreign body removal operation in the First Affiliated Hospital of Yangtze University（Jingzhou First People’s Hospital）from February 2021to October 2022,were randomly divided into two groups:non-intubated THRIVE ventilation group（experimental group）and conventional intubated mechanical ventilation group（control group）,with 23 cases in each group.Oxygen flow rate was 10L/min and Fi O₂ was 100%for 6 min in two groups;and end-expiratory oxygen concentration was measured above 90 after induction of anesthesia was started.All subjects were induced intravenously with sufentanil,propofol,and suxamethonium chloride,and intraoperative anesthesia was maintained with remifentanil and propofol between 2.0 and 3.0 g/m L TCI.After the patient lost consciousness,the oxygen flow rate in group T was modified to 50-70 L/min,whereas group M performed endotracheal intubation for mechanical ventilation（V_T6～8ml/kg,RR10～18 times/min,I:E1:2,oxygen flow rate 1.6L/min）.Fi O₂ 100%was maintained for both groups.Duration of spontaneous apnea to recovery of spontaneous breathing,duration of surgery,duration of awakening（from end of surgery to leave the room）,and anesthesia time（from anesthesia induction to leave the room）were recorded.Sp O₂ of T₁（before anesthesia induction）,T₃（when the esophagoscope was placed）,T₄（when the foreign body was removed）,T₅（removal of the esophagoscope to the end of the procedure）,T₇（when the patient leaving the room）and Sp O₂ in group M in T₂（tracheal intubation）and T₆（tracheal extubation）were recorded.Record of intraoperative minimum Sp O₂ and90%<Sp O₂<95%,oxygen was administered by mask pressure,and placement of nasopharyngeal airway.MAP,HR,BIS of T₁,T₃,T₄,T₅,T₇ in two group and MAP,HR,BIS of T₂,T₆ in group M were recorded.Intraoperative extremum and range of MAP,HR and intraoperative MAP and HR fluctuations compared with those at T₁.The dosage of sufentanil,propofol,and remifentanil.Adverse events（choking and coughing,nasopharyngeal bleeding,nasopharyngeal discomfort,postoperative nausea and vomiting）.Arterial blood gases（Pa O₂,Pa CO₂,p H）were recorded at T₁,T₃,T₄,T₅,T₇,in two groups.Record Pa O₂,Pa CO₂and p H in group T during apnea 5 min,10 min,15min,20 min,25 min,etc.and at the time of respiratory recovery.Patient and surgeon satisfaction were recorded.Results1.Time comparison:duration of spontaneous apnea to recovery of spontaneous breathing,duration of awakening,and anesthesia time were lower in group T than in group M[（13.09±3.82）min vs.（16.83±4.81）min,P<0.05],[（13.09±3.82）min vs.（16.83±4.81）min,P<0.05],[（24.47±2.52）min vs.（31.25±2.84）min,P<0.001],[（38.23±4.90）min vs.（46.86±6.01）min,P<0.001].2.Oxygenation:Sp O₂ in group T was lower than that in group M at T₅[100（99,100）vs.100（100,100）,P=0.01],while Sp O₂ was above 97%in group T at T₅.There was no difference in Sp O₂ between the two groups at T₁,T₃,T₄ and T₇（P>0.05）.There was no difference in the lowest Sp O₂ between the two groups（P>0.05）.The lowest Sp O₂ was above 90%in all the subjects.There was no difference in intraoperative90%<Sp O₂<95%,oxygen was administered by mask pressure,and placement of nasopharyngeal airway between the two groups（P>0.05）.3.Hemodynamics:MAP and HR were higher in the T group than in the M group at T₃,T₄,T₅:[（80.91±8.24）mm Hg vs.（75.57±7.98）mm Hg,P=0.03],[（80.61±8.09）mm Hg vs.（74.61±7.33）mm Hg,P=0.01],[（80.13±8.21）mm Hg vs.（75.39±6.74）mm Hg,P=0.04];[（68.91±9.67）beats/min vs.（63.48±4.56）beats/min,P=0.02],[（68.43±8.96）beats/min vs.（63.87±3.82）beats/min,P=0.03],[（67.35±8.91）beats/min vs.（63.04±4.06）beats/min,P=0.04].The lowest MAP and HR in group T were higher than those in group M[（74.39±6.16）mm Hg vs.（68.74±5.86）mm Hg,P=0.003],[（64.39±8.79）beats/min vs.（60.00±4.59）beats/min,P=0.04].The range of MAP and HR in group T were lower than those in group M[（18.43±4.19）mm Hg vs.（25.48±5.38）mm Hg,P<0.001],[（12.48±3.86）beats/min vs.（18.22±4.12）beats/min,P<0.001].More patients in group T had MAP and HR fluctuations within 20%at T₁ than in group M[10 cases（43.0%）vs.2 cases（9.0%）,P=0.02],[20 cases（87.0%）vs.9 cases（39.0%）,P=0.002].4.Anesthetic drug dosage:propofol consumption and remifentanil consumption in group T were less than in group M[（163.83±46.20）mg vs.（193.98±28.37）mg,P=0.01],[（0.09±0.03）mg vs.（0.16±0.05）mg,P<0.001].5.Adverse events:the incidence of nasopharyngeal discomfort and postoperative nausea and vomiting was lower in group T than in group M[1 case（4.0%）vs.8 cases（35.0%）,P=0.02],[0 case（0.0%）vs.6 cases（26.0%）,P=0.02].6.Pa O₂,Pa CO₂ and p H:At T₃,Pa O₂ in group T was lower than that in group M[（168.55±20.14）mm Hg vs.（208.55±24.06）mm Hg,P<0.001];at T₄ and T₅,Pa O₂ in group T was higher than that in group M[（258.80±70.57）mm Hg vs.（211.87±24.16）mm Hg,P=0.005],[（243.80±61.48）mm Hg vs.（210.55±23.11）mm Hg,P<0.001].At T₃,T₄,T₅ and T₇,Pa CO₂ in group T was higher than that in group M[（47.53±2.77）mm Hg vs.（39.10±2.67）mm Hg,P<0.001],[（57.17±8.91）mm Hg vs.（38.42±2.42）mm Hg,P<0.001],[（62.88±8.06）mm Hg vs.（38.16±2.15）mm Hg,P<0.001],[（41.37±4.17）mm Hg vs.（38.79±2.55）mm Hg,P=0.02].At T₃,T₄ and T₅,p H in group T was lower than that in group M[（7.34±0.03）vs.（7.40±0.04）,P<0.001],[（7.28±0.05）vs.（7.39±0.04）,P<0.001],[（7.29±0.07）vs.（7.40±0.04）,P<0.001].Pa O₂ in group T showed a gradually increasing trend during 15 min of the asphyxia period;it started to decrease at 20 min of apnea;Pa O₂ returned to baseline level when leaving the room.Within 20min of asphyxia,Pa CO₂ in group T tended to increase gradually;it started to decrease when respiration recovered;and returned to baseline level when leaving the room.Within 20 min of asphyxia,p H in group T tended to decrease gradually;it started to increase when respiration was recovered;it returned to the normal level when leaving the room.7.Satisfaction:patient satisfaction（P<0.05）and surgeon satisfaction（P<0.001）were better in group T than in group M.ConclusionThe apnea time is prolonged while supporting effective intraoperative oxygen supply with THRIVE during general anesthesia for upper esophageal foreign body removal surgery.At the same time it can maintain intraoperative circulatory stability,reduce the consumption of anesthetic drugs,shorten the awakening time,reduce the incidence of nasopharyngeal discomfort,postoperative nausea and vomiting,and require high patients and surgeon satisfaction.However,it is necessary to be alert to the problem of transient increase in Pa CO₂ and decrease in p H during spontaneous apnea period.